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Empowerment in the context of trauma 03/31/2011

Posted by ALT in Philosophy/Spirituality, Treatments.
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Empowerment: the new favorite buzzword of mental health policymakers.  I’ve already mused a little bit about what that word might mean – both to them [certainly not having much to do with agency or self-actualization] and those of us interested in practicing true psychiatry (literally, soul healing).

A few more thoughts about empowerment in the specific context of trauma and trauma resolution, drawn mostly from famed trauma specialist and mind-body healer Dr. Peter Levine’s book Waking the Tiger.

According to Levine, trauma response is a necessary survival skill common to all members of the animal kingdom, and there are three basic, built-in strategies: fight, flight, or freeze.  After the previous two efforts (fight or flight) have failed, action is suspended and the intense survival energy is literally frozen in the motionless body of the prey.  This “freeze” response  is helpful for a couple reasons: 1. playing dead may lure the predator into a false sense of security, allowing for future escape 2. if escape is not possible, it is the body’s natural anesthesia for the coming pain of death.  Interestingly, for the prey who escape the event is not over until the discharge of the frozen energy – via convulsions or shaking — occurs.  It is an essential and instinctive conclusion to the traumatic episode.  It is how they move on with their lives sans emotional baggage/trauma.

Again, this is a response seen in all members of the animal kingdom; the gazelle trapped in the jaws of a tiger, the mouse being batted around by your adorable tabby cat.  The frozen, seemingly lifeless body.  The surge of energy and quick escape at the opportune moment.  And then the shaking or convulsions afterwards — a release of the stored energy.

The “release of energy” part  is where human beings can get into trouble.  A lot of times our natural traumatic response does not reach its instinctive conclusion, and instead the energy is trapped in an ever-deepening cycle inside the body, undischarged and untamed.

So a complete trauma response looks like this:

And an incomplete response looks like this:

Levine’s premise (based on over 20 years of clinical work with the traumatized) is that the trauma response can be completed at any time – even many years later.  What is essential to completing the response [ie, healing] is not necessarily a cerebral re-living or re-telling of the memory (though this could help), but allowing the body to experience the completed, successful response, and to achieve the empowering reality of a challenge (trauma) successfully met. 

So in the context of traumatic response, empowerment is an instinctive self-actualization.  The means to achieving a complete trauma response are built in, biologically, to the mammalian brain

Which means: self-actualization doesn’t have to be an entirely esoteric, philosophical pursuit!  

And you don't have to read all/any of these.


Great news, because overly cerebral processes often end up feeling artificial and insincere.  A healthy dose of instinct can clear that right up.

Empowerment/self-actualization 03/29/2011

Posted by ALT in Philosophy/Spirituality.
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You remember that 2006 NASMHPD report on morbidity in the “seriously mentally ill” population, so often cited in the current literature, the main navigational tool charting the course of mental health policy for the past decade or so (that I wrote about here and here)?  One of the main policy recommendations to come out of that report was that caregivers should “support wellness and empowerment of persons served, to improve mental and physical well-being.” 

Sounds good, but don’t be fooled – they didn’t really mean that.  What they want is to “empower individuals to engage in services” – empower people to become lifelong consumers.  What they want is controlled [false] empowerment as a strategy for achieving lifelong treatment plan adherence (non-compliance/non-adherence being the $100,000,000,000 problem for pharmaceutical companies – their words.) 

Despite the insincerity, the basic policy recommendation for empowerment got me to thinking.  What would true empowerment amongst the seriously mentally ill population (or anyone, for that matter) look like? 


Define the terms

By now, you’re probably aware – I view words as living entities with history.*  Knowing this history is key to using language precisely (ie, making it work for you as opposed to expressing the message of someone else attempting to exert hegemonic control over thoughts and ideas). 


1: to give official authority or legal power to.  2: ENABLE.  3: to promote the self-actualization or influence of.


1: to make actual; REALIZE.  (self-actualize: to make oneself real or actual)

To make oneself real.  That’s a very interesting concept.

[NOTE:  the word is “self-actualize.”  As in “do-it-yourself.”  This means that you cannot “self-actualize” someone else; only you can self-actualize yourself. 

Again, this means that you can’t manipulate or talk someone into self-actualizing, you cannot plant the idea to do it in someone else’s head [inception], even if you have decided (out of love, paternalism, condescension, or compassion) that it would be “for their own good.”]

I find it more useful to speak of “supporting the empowerment/self-actualization” of someone else; this phrasing makes it clear who’s in charge.  Our hero, seeking empowerment and self-actualization, by asking that all important question “Who am I?” Or, perhaps, “Who am I in the context of my community, my life-world?” Our hero is the owner of the process; we (the supporters) are merely the furniture in the house that he built.  Useful – yes.  Something to lean on – certainly.  And that’s it.


To make oneself real

Now we’re getting into philosophy here, but there are a few things to be said about our hero’s [everyone’s/our] quest that apply at a larger-than-the-individual scale.

 The first being that self-actualization must, by definition, be a subjective, individualized process.

Do you require community to be real?  Relationships with friends and family, affirmations from the culture as a whole that you are a worthwhile person, that you are an agent?  Or does self-actualization consist of a sort of feedback loop between your body, mind, and soul, your actions and your thoughts [ie, the actualizing activity is taking place internally]?  This may be culturally determined… or it may be your entirely conscious choice. 

Empowerment for me will look different than empowerment for you. 

Diversity!  Difference! Life!

How exciting.

Self-actualization cannot be compartmentalized.

Can you be self-actualized in your professional life, but remain a non-entity when it comes to dealing with your family?  Or with past trauma?  Or with authority figures in your life (be they doctors, teachers, government officials, et al)? 

Emphatically, NO. 

It just doesn’t work that way.  Being real means being in reality – all of it.  The good, the bad, the ugly.  Any attempt to abbreviate your realness, confining it to a self-constructed category, will bring with it, inevitably, despair.  

This applies to everyone.  I especially like the way that Eduardo Duran applies this concept to those therapists who think they can be “healers” in their professional lives while being desperately in need of healing in their own personal lives:

The identity of the healer is critical.  Over the years, I have always asked interns and staff a simple question: “Who are you?”  The question is not rhetorical, and the answer requires exploration into who they are as a person, who they are in the healing situation, and who they are in their life-world… Very few of the interns understand the question of identity as one relating to who they are as a spiritual being.  The importance of spiritual identity starts to become clear as they begin to understand that a relationship with spiritual entities is part of the work that we do in the clinical world.

In most Traditional Healing cultures, the Healers embody the healing energy in their life and in all that they do.  Western healers have a way of compartmentalizing their role as a healer from what they do in “real life.” …

At this point, I ask the reader who is interested in the healing process, “Who are you?”  If you are interested merely in techniques that will ameliorate behaviors in the short and even long term, then these ideas may not be for you.  However if you are even remotely interested in the notion of soul healing from the ongoing soul wounding that is encountered in every aspect of life in the modern corporate world, then I encourage you to read on…

Your own soul must be healed so that you can attend to the patient who is presenting with a wounded soul.  You cannot do for others what you haven’t done for yourself.

(Eduardo Duran, Healing the Soul Wound)

To self-actualize: to heal your own soul?  And, having healed your soul, to lead by example the rest of us who seek healing [self-actualization] ourselves?

* I’m talking about LOGOS, the living word.

“In the beginning was the Word [LOGOS], and the Word was with God, and the Word was God.  He was with God in the beginning.  Through him all things were made; without him nothing was made that has been made.  In him was life, and that life was the light of all mankind.  The light shines in the darkness, and the darkness has not overcome it.  (John 1:1-5)”

Turning suffering into healing 03/25/2011

Posted by ALT in Philosophy/Spirituality, Quotes.
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“Violence has an energy to it.  Some Traditional beliefs have it that violence is actually a spirit.  Spirit can move from place to place and even across the generations.  You know, unless someone with “medicine” does something about it… 

If you can see how violence or anger were passed down to you from previous generations, that puts you in a very powerful place.  You can heal your great grandparents, your parents, and all the way up the line.  You also can heal all of your children and their children by healing yourself.  You see, this is the only place that the ancestors can heal their soul wound.  They didn’t have the opportunity to heal when they were alive, so the energy of the anger was passed on down.  Now that you understand, you can bring a lot of “medicine” to your family…

 This is an existential moment for the patient in which his personal anger and sadness are given a special power to heal what means the most to him.  Therefore, we are turning suffering into healing… ”

(Eduardo Duran, Healing the Soul Wound)

A response to a Cracked.com article 03/23/2011

Posted by ALT in Humor, Patient Rights and Advocacy.
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In order to infuse my posts with humor, I make it a habit to read Cracked.com almost daily; it’s one of the best satirical websites around (superior even to the Onion, in my humble opinion).  But when I saw Item #5 in this article today, I didn’t find it particularly funny.  It speaks to me of a trend — accelerating rapidly now because of the Jared Loughner incident — towards involuntary institutionalization of the mentally ill.  I couldn’t let it stand; I had to raise my voice.

This is what I wrote to the author of that article:

Dear Diana,

I’m a big fan of Cracked… it’s a great source of humor, but, even more important, ya’ll are often DEAD ON when it comes to critiquing the madness this society embraces with open arms.  So I’ll frankly admit I consider Cracked to be a good source of social commentary and information as well (and I bet I’m not alone in that…).

Which is why, Diana, I feel it necessary to share some information with you concerning your most recent article [“5 Useful Organizations You Think Are Evil (Thanks to Movies)”].  I understand that as a satirical writer you may sometimes need to bend, stretch, or exaggerate (though our society is ridiculous enough that usually it’s unnecessary)… but most of what you write about Hollywood portrayals of mental institutions under Item #5: Insane Asylums is sadly misinformed.  Allow me to share some information with you: 

1. You write that Hollywood falsely portrays asylums as places where “you’re… going to be held against your will and tortured by malevolent nurses with electroshock.”

Forced electroshock is NOT a thing of the past.  It’s actually pretty common.  Nearly 100,000 Americans will receive ECT [electro-convulsive therapy] this year, and while there aren’t specific statistics available for the US, in the UK it was found that 59% of ECT treatments were involuntary.  [more info here].

To make it more personal, let me tell you about Elizabeth Ellis, of Moorhead, Minnesota.  Earlier this winter, Elizabeth experienced a dozen court-ordered electroshocks.  She found them terrifying and unhelpful.  Finally, she had enough – on January 27, she stayed home instead of going to her “treatments.”  Police were sent to fetch her from her house, and she has now been involuntarily committed to a psychiatric institution, where the involuntary ECT continues.  MindFreedom International has started an advocacy campaign on her behalf.  I encourage you to take a look and see if there is something you can do.

Here’s another case: Paul Henri Thomas, a Haitian immigrant signed a consent form for ECT at the Pilgrim Psychiatric Center (where he was involuntarily committed) in June, 1999.  He underwent the treatment three times in June, but after the third treatment he refused to sign any more consent forms.   And that’s when his doctors decided that he was no longer competent to give consent and would be subjected to involuntary ECT.  He went to court for his right to refuse the treatment… and lost.  Ultimately, he was involuntarily shocked almost 60 times.  Here’s an instructive excerpt from the court proceedings:

At the third day of Thomas’ hearing yesterday, his attorney questioned a witness for Pilgrim.

“In June he was competent to consent and received three treatments, and some time after that he became incompetent. Is that correct?” asked Kim Darrow, an attorney for the state Mental Hygiene Legal Service, which is representing Thomas.

“I’m unable to answer that,” responded Dr. Robert Kalani, Pilgrim’s associate medical director.

But State Supreme Court Justice W. Bromley Hall swiftly cut off Darrow’s line of questioning, saying Thomas’ capacity to make decisions about his health may have changed since he consented to the treatment.

“There are a lot of people walking around with capacity for whatever,” Hall said in the Central Islip courtroom. “The fact that you have capacity today doesn’t mean you will have capacity tomorrow,” he added, prompting gasps from Thomas’ supporters…

Testimony ended with Darrow asking Kalani, given that Thomas has called the procedure “torture” and “evil,” how has it improved his life.

“Do you think you have improved the quality of life for Mr. Thomas?”

“I think we have,” Kalani answered.


2. Another false portrayal of mental institutions, you say, occurs “in Batman Begins, where a crazy administrator gives patients hallucinogens that induce nothing but bad trips.”

Actually, there’s a whole genre of psychiatric experimentation called “symptom-exacerbation experiments,” where researchers deliberately induce or exacerbate states of psychosis and mania in order to study their progression or test remedies.  You see – the occurrence of psychosis is pretty unpredictable, making experimentation difficult; if it can be induced at a pre-determined time, it is much more experimentally convenient.  In the 1950s and 60s, as you are probably aware, these experiments included dosing people with LSD and other hallucinogens (one example here).

There was a bit of a public outcry in the early 70s, but by the 1980s symptom-exacerbation studies were again a hot topic because a of the dopamine-causation hypothesis for schizophrenia.  This time, stimulants like methylphenidate (synthetic cocaine, AKA Ritalin) and other amphetamines – known to exacerbate or cause psychosis — were also used.  These symptom-exacerbation studies are a thing of today, not the past.  Here are a few recent examples: this experiment (1993), this one (1997), and this one (1991).  What I’ve linked to our academic articles published in prestigious journals.  This points to the fact that the practice is accepted, and mainstream (given, of course, that the researcher masks what he’s doing with incredibly technical and dispassionate (ie objective/scientific) language).

Have you ever heard the story of Shalmah Prince?  She’s a portrait artist from Cinncinnati, and in the late 70s she was diagnosed with bipolar disorder.  In 1983, after going to the hospital voluntarily for treatment (she feared she was about to have a manic episode and wished to avoid it) she was enrolled in a study.  She signed a consent form which read, “I, Shalmah Prince, agree to participate in a medical research study the purpose of which is to clearly diagnose my illness and determine whether treatment with lithium might provide long-term relief of my symptoms.”  She didn’t have insurance and desperately needed treatment… it seemed like the best option at the time.

What actually happened was that she was abruptly withdrawn from lithium, which she had been taking for several years, and then injected with apomorphine, known to cause psychosis (withdrawal from lithium alone can cause psychosis/mania, too, especially if done abruptly without any tapering).  In short, she was involved in a symptom-exacerbation study.  Naturally, she soon suffered a severe manic/psychotic break.   She was left in leather restraints for three days, and she herself says “After that, I was never the same person ever again.”  She was severely traumatized.  She was also billed nearly $15,000 upon discharge from the hospital.  She lost most of her memory of the event, but in 1994, after reading a newspaper article on symptom-exacerbation studies, she slowly pieced together what happened.  She forced the hospital to produce her medical records and attempted to sue; but she was unable to because the statute of limitations was only 2 years (trauma-induced memory loss being no excuse, I suppose).

Diana, I again stress to you that this is not ancient history… this is the present!  Forced drugging, social isolation, stigmatization, beatings, confinement, etc. are also standard practice in institutions.  For these reasons, I feel confident in stating that folks who are fearful of or resistant to involuntary commitment to asylums/mental institutions are completely justified.  I support their right to determine, for themselves, what “wellness” is, and what treatments they think would be helpful. 

And please don’t make the mistake of thinking that the seriously mentally ill are somehow “other,” that “this could never happen to me.”  Oh, how many have thought that!  Diana, it [an “extreme state of consciousness,” as they say] could happen to anyone. 

So understand that I also support your right to refuse ECT, drugging, or commitment to a mental institution you don’t think would be helpful, Diana.   I support your human right to define wellness for yourself.

In light of the recent Tucson shooting and the media bonanza concerning Jared Loughner (which has people, and LEGISLATORS, glibly calling for more and more involuntary commitment to “protect” the public from “psychotics”)… this issue is only going to get bigger and bigger.  I urge you to reconsider what you have written in your article… I urge you to consider the very salient points of the mental health rights movement … I urge you to consider the tenants of the “Universal Declaration of Mental Rights and Freedoms”…

And most of all, I urge you to remember the parable of the Holocaust, which I find imminently applicable to this situation:

“First they came for the Jews
and I did not speak out –
because I was not a Jew.
Then they came for the communists
And I did not speak out –
Because I was not a Communist.
Then they came for the trade unionists
And I did not speak out—
Because I was not a trade unionist.

Then they came for me—
And there was no one left
To speak out for me.”
(Pastor Niemoeller, victim of the Nazis)

Diana, did you know that, actually, they came for the mentally ill first, before anyone else?  Food for thought…

Yours truly,

Two “Therapy Tales” cartoons 03/23/2011

Posted by ALT in Humor.
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This two cartoons come from Therapy Tales, a blog I recommend visiting regularly – we need a little more humor in this ever-so-serious mental health discussion!  (I post these also because they’re particularly relevant to the “25 years statistic” and the SAMHSA 10×10 Wellness Campaign — both of which have been discussed recently on ALTmentalities.)

Menthol Health:




[reposted with permission from the author]

The human right to be psychiatrized? 03/22/2011

Posted by ALT in Children's Mental Health, Mental Health News.
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Yesterday, under the headline “Psychologists seek authority to prescribe psychotropic medications,” The Washington Post published a re-hash of a familiar frame story, one which I like to call the “undiagnosed and untreated” frame.  It goes something like this:

1.  Lots of people — adults and kids, American or otherwise — are suffering from mental illness; and many of them are not being treated (the implication typically being that “treatment” = primarily drug therapy).  Something must be done.

2.  People don’t have proper access to mental health experts, folks who can provide them with the treatment [medications] they require.  That’s because a. states are cutting spending on mental health services and b. there just aren’t enough psychiatrists, especially in non-urban areas.  Something must be done.

3.  Mental illness is serious and real [insert mention of chronic physical illness like “diabetes” here].  After all, “people with serious mental illness die 25 years earlier, on average, than the rest of the population.*  Something must be done.

4.  Finally, after the case for doing something has been so irrefutably established, the recommendation is usually along the lines of making medication more accessible, either by reforming insurance reimbursement practices, integrating mental health care with primary health care, or (as is the case in this article) recommending that all psychologists – not just clinical psychologists with training in psychopharmacology – be allowed to prescribe medications.

This frame story presents undiagnosed/untreated mental illness almost as a human rights issue.  From this point of view, it is a basic human right to a. be informed that you are suffering from a mental illness [this fact being objectively determined, of course] and b. be medicated, therapized, or in some other way treated for that disease [the treatments being scientifically proven to address those aforementioned objective diagnoses].  Keeping in mind the funny way that informed consent operates in mental health “care,”** it’s fair to say that it doesn’t really matter if you agree with the label you’re given or the means of addressing that label [treatment].  For your own good, and the good of society, you must be treated; otherwise harm to yourself or others is the inevitable result – or so we’re told.  The glut of editorials following the Tuscon shooting warning that untreated mental illness will lead to violence (not supported by any evidence beyond conjecture) is an excellent example of this particular misconception at play.


Case Study: the right of children to be bipolar

A recent study from the Archives of General Psychiatry, detailing the prevalence of diagnosed bipolar spectrum disorders in different countries, showed the following results: essentially, the United States has the highest rate of diagnosed bipolar disorders (4.4%), almost twice the estimated worldwide average (2.4%).

click to enlarge

[citation: Merikangas, K.R. et al (2011).  Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey InitiativeArchives of General Psychiatry, 68(3), pp 241-251.]

The interpretation of this data was another homage to the “undiagnosed and untreated” frame story; bipolar disorders are real but they’re not being diagnosed properly worldwide (just look at the disparity between the US and other countries!).   Folks in under-developed countries are being denied their basic human right! Something must be done.

In fact, before the 1990s, the US’s rate of bipolar disorder was much lower, mainly because the phenomenon of childhood bipolar disorder was unknown.  It was something a clinician could expect to see maybe “once or twice in his lifetime.”  But then in 1994 two influential child psychologists from Harvard University, Dr. Joseph Biederman and Dr. Janet Wozniak, hypothesized that the disease is common in children – and is often misdiagnosed as ADHD. 

Overnight, bipolar disorder diagnoses in children soared; there was a 40-fold increase between 1993 and 2003 in bipolar labeling (4000%!).   

This precipitous increase in diagnosis (and corresponding increase in profits for the manufacturers of medications used to “treat” the disorder) doesn’t look… natural.  Especially when you have child psychiatrists admitting on primetime TV that the whole thing is an “experiment.”  So there’s been a bit of a backlash, and the DSM-V [Diagnostic and Statistical Manual, 5th Edition, currently in development] will address the problem—a new diagnosis for what is now called “childhood bipolar disorder” has been invented.  They’re calling it “Temper Dysregluation Disorder.”  It is a “biological dysfunction,” to be treated with medication, of course.

I fear that we’ll soon be meeting individuals who insist that they suffer from “Temper Dysregulation Disorder,” that the label finally puts a face to the beast of the problems they’ve been facing for years.  Maybe so — but I won’t be able to stop myself from remembering the days when that label was just the figment of a DSM-V editor’s imagination…

... and Pluto was still a planet.


A pertinent question

If this new diagnostic category does indeed become the psychiatric law of the land in the DSM-V, what will this mean for the thousands of children who suddenly had the human right of being bipolar thrust upon them?  Will it be their new human right to be “reclassified” into another diagnostic/pathologic category? 

Will we soon be informed that the rates of “Temper Dysregulation Disorder” diagnosis are pathetically low in foreign countries, and that those poor suffering individuals need to have their human right to diagnosis and treatment met, whether they like it or not?

One thing is certain; as long as new psychiatric disorders are invented solely in the US (and it appears that for now at least the APA has a monopoly on that activity), the rest of the world is just going to have to put up with shrill condemnations of their human rights violations.  Unless, of course, they have the money, time, and will to subject their populations to the kind of psychiatrization so popular here in the US.


* Bonus points if you can spot the inaccuracies surrounding the Washington Post’s presentation of this statistic…

** Someone who says “yes” to treatment is almost always “competent to give consent;” someone who says “no” is demonstrating his pathology, inability to make good judgments about his own care, legally incompetent – and subject to involuntary treatment and confinement.  Like the case of Paul Henri Thomas, to cite just one example.

On Subjectivity 03/20/2011

Posted by ALT in Quotes.
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No, it’s impossible; it’s impossible to convey the life-sensation of any given epoch of one’s existence — that which makes its truth, its meaning — its subtle and penetrating existence.  We live as we dream — alone…

(Josef Conrad, Heart of Darkness)

Guidelines for Empathic Therapy 03/18/2011

Posted by ALT in Treatments.
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The Center for the Study of Empathic Therapy, Education and Living is a project spearheaded by Dr. Peter Breggin (psychiatrist, medical expert, psychiatry’s main “anti-psychiatry” activist… and author of numerous books including Medication Madness).  But it is by no means a dictatorship; a brief look at the Advisory Council list shows that constituents from across the board are involved – from psychiatry to counseling, obstetrics, law, and of course advocates and psychiatric survivors (notably Mary Maddock, a very eloquent critic of ECT [electro-convulsive therapy] and co-founder of MindFreedom Ireland). 

So whatever you may think of Dr. Peter Breggin personally, have a look at the recently released “Guidelines for Empathic Therapy,” conceived of and developed by Breggin in partnership with the entire Advisory Council.  Though not flawless, I find them to be truly inspiring and hope that more and more therapeutic relationships will come to resemble the vision they lay out here:   


Guidelines for Empathic Therapy

As empathic therapists:

(1) We treasure those who seek our help and we view therapy as a sacred and inviolable trust. With humility and gratitude, we honor the privilege of being therapists.

(2) We rely upon relationships built on trust, honesty, caring, genuine engagement and mutual respect.

(3) We bring out the best in ourselves in order to bring out the best in others.

(4) We create a safe space for self-exploration and honest communication by holding ourselves to the highest ethical standards, including honesty, informed consent, confidentiality, professional boundaries and respect for personal freedom, autonomy and individuality.

(5) We encourage overcoming psychological helplessness and taking responsibility for emotions, thoughts and actions — and ultimately, for living a self-determined life.

(6) We offer empathic understanding and, when useful, we build on that understanding to offer new perspectives and guidance for the further fulfillment of personal goals and freely chosen values.

(7) When useful, we help to identify self-defeating patterns learned in childhood and adulthood in order to promote the development of more effective choice-making and conduct.

(8) We do not treat people against their will or in any way use coercion, threats, manipulation or authoritarianism.

(9) We do not reduce others to diagnostic categories or labels — a process that diminishes personal identity, over-simplifies life, instills dependency on authority and impedes post-traumatic growth. Instead, we encourage people to understand and to embrace the depth, richness and complexity of their unique emotional and intellectual lives.

(10) We do not falsely attribute emotional suffering and personal difficulties to biochemistry and genetics. Instead, we focus on each person’s capacity to take responsibility and to determine the course of his or her own life.

(11) We recognize that a drug-free mind is best suited to personal growth and to facing critical life issues. Psychiatric drugs cloud the mind, impair judgment and insight, suppress emotions and spirituality, inhibit relationships and love and reduce willpower and autonomy. They are anti-therapeutic.

(12) We apply the guidelines for empathic therapy to all therapeutic relationships, including persons who suffer from brain injuries or from the most profound emotional disturbances. Individuals who are mentally, emotionally and physically fragile are especially vulnerable to injury from psychiatric drugs and authoritarian therapies, and are in need of the best we have to offer as empathic therapists.

(13) Because children are among our most vulnerable and treasured citizens, we especially need to protect them from psychiatric diagnoses and drugs. We need to offer them the family life, education and moral and spiritual guidance that will help them to fulfill their potential as children and adults.

(14) Because personal failure and suffering cannot be separated from the ethics and values that guide our conduct, we promote basic human values including personal responsibility, freedom, gratitude, love and the courage to honestly self-evaluate and to grow.

(15) Because human beings thrive when living by their highest ideals, individuals may wish to explore their most important personal values, including spiritual beliefs or religious faith, and to integrate them into their therapy and their personal growth.

SAMHSA’s 10×10 Wellness Campaign — spawned by a statistic, and doomed from the start 03/17/2011

Posted by ALT in Mental Health Policy and Inititatives, Patient Rights and Advocacy.
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“The seriously mentally ill die, on average, 25 years earlier than the general population…”

Yes, in 2006, this statistic, one sentence gleaned from a 50+ page report by the National Association of State Mental Health Program Directors [NASMHPD], made a big splash. 

And as pointed out recently here, though the report does acknowledge psychotropic drug use and polypharmacy as causative factors for this horrible trend in mortality of the mentally ill, the report’s foremost policy recommendation for care providers is to promote compliance with treatment regimens despite side effects, meanwhile creating a [false] feeling of empowerment and equality in mental health patients/consumers merely by changing the language of  “compliance” to “adherence,” and by encouraging patients to “ask questions.”

Ah, but it’s a thing of the past!  This is 2011 – what do a few offensive policy recommendations from 5 years ago have to do with the present?



Spawn of a statistic

This report was THE inspiration for the SAMHSA 10X10 Wellness Campaign, launched about a year ago, whose mission is to “to promote wellness for people with mental illness by taking action to prevent and reduce early mortality by 10 years over the next 10 years.” 

Anyone with knowledge of the mortality of the seriously mentally ill that extends beyond page 5 of the NASMHPD report [which is where it seems most people gave up reading the damn thing] would expect a campaign with that kind of a goal to seriously address issues of polypharmacy, iatrogenically caused illness, the debilitating effects of long term psychotropic drug use, etc – as these things play a very important role in the increased rates of diabetes, heart disease, high cholesterol, and obesity in this population.

But, like the report that spawned it, this campaign, of course, does nothing of the kind.  [And the campaign is therefore doomed; without addressing this issue they cannot hope to achieve the abovementioned goal.]

Instead, the emphasis is on re-defining terms, creating false empowerment amongst consumers, promoting medication “adherence,” and extensive and invasive data collection on the mentally ill population.


Re-defining terms

What is wellness?  Because you can’t very well have a wellness campaign without defining that

[And, please, let’s not even think about letting folks define wellness subjectively, on an individual level, based on their own experiences, preferences, wants, desires, values, etc.  Because you can’t standardize subjective definitions – and anyway that kind of approach would tend to make SAMHSA superfluous.  And we are talking about 100s of jobs here!]

No, here is how wellness is defined:

[click image to enlarge]

What I think is key is the sidebar; first, the image of the stethoscope (that stands for “doctor”), practically strangling the statement “Wellness connects all aspects of health” and of course this quote:

Communication among mental health consumers, professionals, and primary care providers about health information is essential to overall wellness.

(from the SAMHSA 10×10 Wellness Campaign’s “8 Dimensions of Wellness” promotional poster)

Not only is SAMHSA dictating that the professional medical establishment’s involvement in your life is essential to overall wellness, but this also feeds right into the data collection goal: providing the medical establishment with whatever health information they require (and if I know evaluation – which I do – it’s going to be a lot) is also an “essential” part of that wellness.

In the 10×10 Wellness Campaign’s brochure for consumers, the same definition of wellness (8 dimensions) is used, with a small caveat at the end that it may “differ from person to person.” 

Very little room for individual difference in that already overcrowded Venn diagram on steroids…

Wait... there it is!

The message is clear: wellness has nothing to do with trusting yourself (instead, trust the medical establishment) and polypharmacy/iatrogenic illness is certainly not part of the picture.  In fact, SAMHSA’s idea of achieving wellness could be summed up like this:

In addition to doing whatever the medical establishment tells you to, you people need to quit smoking, quit eating junk food, and get off your off your butts and exercise. *

Oh, ok.


Promoting “adherence” and creating false empowerment

Let’s start with the basics: if you clicked the link to the 10×10 homepage, you may have noted that the URL is actually www. “promote acceptance”. samhsa.gov/10by10. 

Promote acceptance of what? 

Nowhere in the stated goals of the campaign is the word “acceptance” even used… (they do, however, note that the mortality rate for the seriously mentally ill is “unacceptable.”)

My friends, though SAMHSA would likely argue this is meant to be a statement against stigmatization of the mentally ill, I am more inclined to interpret this as part of their “adherence” agenda.  Promote acceptance of… whatever the medical establishment tells you to accept, be it diagnosis as identity, medication for life, chronic illness, et al.

There are stronger evidences of this agenda elsewhere, of course.  Take the campaign’s “3 Ways to Promote Wellness” poster, for example.  Patients are reminded that “communication between people with mental health problems, mental health professionals, and primary care providers is essential” and to “review and act on results of check-ups and health screenings” (ie, fill those prescriptions).

Remember the irony here: the original 2006 NASMHPD report did acknowledge polypharmacy and long-term psychotropic drug use as significant causative factors of the mortality rates of the seriously mentally ill, and then turned right around and stressed compliance with medication-centered treatments.  It seems SAMHSA has pulled the same Orwellian maneuver.


A wellness campaign for whom??

So I am compelled to ask: whose wellness is the SAMHSA 10×10 Wellness Campaign talking about?  Without addressing polypharmacy and iatrogenic illness, it seems obvious the answer is not “the seriously mentally ill.” 

No, I think we are talking about the financial and corporate wellness of the medical establishment and SAMHSA itself, because the campaign stresses, repeatedly, how essential they are to “wellness.”  As previously mentioned, that’s a lot of jobs – a lot of house payments, kids in college, newly-constructed vinyl suburban homes with Toyota Camrys and Ford Expeditions (and perhaps even the occasional Cadillac Escalade!) parked in the driveways.

In the name of job security…

Actually, it feels pretty good to be a small time gansta, too.


* Thanks to commenter Darby Penney for summing it up so nicely the other day.

“The seriously mentally ill die, on average, 25 years earlier than the general population…” 03/15/2011

Posted by ALT in Mental Health Research, Treatments.
Tags: , , , , , , ,


(exploring the source of a statistic)

Are you familiar with this oft-quoted statistic: “people with serious mental illness served by the public mental health system die, on average, 25 years earlier than the general population”?  You see it everywhere – for example in TIME magazine, USA Today, and throughout the mental health blogosphere.

It comes from this 2006 report on mortality and morbidity in the seriously mentally ill population published by the National Association of State Mental Health Program Directors [NASMHPD].  The report also contains several other [less frequently quoted but no less powerful] statistics.  Consider:

  • suicide accounts for 30% of excess mortality [in the population suffering from “serious mental illness”], but 60% of premature deaths are due to other causes such as cardiovascular and pulmonary disease, obesity, and smoking – causes which are in some ways preventable.
  • people diagnosed with schizophrenia are 2.7X more likely to die of diabetes than the general population; 2.3X more likely to die of cardiovascular disease, 3.2X more likely to die of respiratory disease, and 3.4X more likely to die of infectious disease.  All of these causes of death are exacerbated by the following risk factors – obesity, smoking, diabetes, hypertension, and dyslipidemia [high blood cholesterol] – which are, again, significantly more prevalent amongst this population.

These are shocking things for science to say, surely a kind of gauntlet thrown at the feet of this population and those who serve/support/love them.

Methinks a champion is required; and this guy is probably NOT it.

What causes this shocking mortality/morbidity problem, and what can be done?


Are you thinking what I’m thinking?

In light of all that we’ve recently learned about psychotropic medications, antipsychotics in particular (causing brain shrinkage, diabetes, obesity, heart disease, et al): does the NASMHPD report have the guts to honestly own up to the fact that most of the abovementioned risk factors can often be traced back directly to the psychotropic medications so glibly prescribed to this population?  Actually, they do a pretty good job, acknowledging all of the following:

Residence in group care facilities and homeless shelters (exposure to TB [tuberculosis] and other infectious diseases as well as less opportunity to modify individual nutritional practices)… symptoms associated with serious mental illness [such as] feelings of hopelessness and powerlessness, learned helplessness…

Psychotropic medications may mask symptoms of medical illness and contribute to symptoms of medical illness and cause metabolic syndrome… [and] polypharmacy [is] identified as a risk factor for sudden death.

(from the 2006 NASMPHD report on mortality in the mental health population)


Seeing such promising signs – a willingness to acknowledge these usually unspoken-of risk/causative factors – I eagerly turned to the “Policy Recommendations” section…

Only to be severely disappointed.  Nothing addresses the risk factors listed above.  NOTHING.

[alright – they did briefly mention a tool used in New York State hospitals to insure folks weren’t prescribed 3 or more antipsychotic medications at the same time but that was just a subordinate clause in a very long sentence buried near the bottom of page 47… and I feel that’s just a tad inadequate, don’t you?]

Here’s what they do instead:


Policy Recommendations?  Change the language, of course…

The “Policy Recommendations for Providers and Clinicians” section starts out with some powerful and exciting language: mentally ill people must be assisted in finding “hope for tomorrow” and to “understand the hopeful message of recovery.”  They must be “enabled to engage as equal partners in care and treatment” and “empowered.”

But what is really meant is that the language must be changed so that these things are implied, while treatment remains largely the same.  Here is how NASMHPD recommends achieving a “partnership with the people we serve:”

Agree on a Treatment Plan

“Adherence” is the goal because it implies sticking to a collaboratively developed plan, as opposed to the more directive term “compliance.”  Six specific actions can increase the likelihood of adherence: keep the regimen simple, write out treatment details, give specifics about the expected benefits of treatment and the timetable, prepare the patient for side effects and optional courses of action, discuss obstacles to moving forward with the regimen, and get patient feedback.

(from the 2006 NASMHPD report)

So partnership” between providers and “consumers” is to be achieved by a mere change of language (from “compliance” to “adherence”), which no longer implies the directive (ie use of force), power flowing from provider to patient.  Never mind that involuntary commitment and treatment of the mentally ill is as frequent a practice as ever, and that a patient’s supposed mental competence/ability to provide informed consent is often judged solely on the basis of the patient’s willingness to “adhere” to whatever lucrative treatment the doctor prescribes (take for example the strange case of Paul Henri Thomas, who was competent as long as he said “yes” to expensive ECT treatments, but was immediately “incompetent” upon refusing treatment).

What’s more, from the NASMHPD’s above use of the terms “regimen” and “side effects,” it’s clear they’re mainly talking about treatment centered on medication.

So in an almost incomprehensibly illogical turn of events, the NASMHPD first acknowledges that psychotropics and polypharmacy are causative factors for the increased mortality rate of the seriously mentally ill population, and then strongly emphasizes in the policy recommendations section the importance of compliance with/adherence to medication regimens!


What’s the big deal?

Ok. So the NASMHPD put out a lousy report in 2006 that, while acknowledging the mortality rate for the mentally ill population, failed to make good policy recommendations addressing its own listed causative/risk factors… so what?

What it boils down to is there’s a reason this statistic is quoted so often (a reason apart from its shocking nature).  The NASMHPD report forms the very foundation of some of the most important nationwide “official” mental health initiatives — and what I mean by that are SAMHSA [Substance Abuse and Mental Health Services Administration] and DHHS-funded [Department of Health and Human Services] initiatives.  These initiatives are meant to address the issue of mortality of the seriously mentally ill population; but they’re also taking their cues from the fatally flawed “Policy Recommendations” section… and that’s not a good thing.  In fact, it’s the most self-defeating setup imaginable.

There’s a lot more to say about this, so meet me here tomorrow — same time, same place — and we’ll talk.



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